Provider Demographics
NPI:1851809388
Name:GALLON, OCTAVIA ALICIA (LPC)
Entity Type:Individual
Prefix:
First Name:OCTAVIA
Middle Name:ALICIA
Last Name:GALLON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2232 DELL RANGE BLVD STE 270
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82009-4980
Mailing Address - Country:US
Mailing Address - Phone:307-222-9015
Mailing Address - Fax:
Practice Address - Street 1:2232 DELL RANGE BLVD STE 270
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82009-4980
Practice Address - Country:US
Practice Address - Phone:307-222-9015
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-18
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPPC-1048101Y00000X
WYLPC-1899101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY148935600Medicaid